Working in a children’s hospital has certainly given me a new perspective on many aspects of pediatric care, both in the emergency and non-urgent settings. One of the biggest changes to my approach with kids is pain management, but not quite in the way that you might be thinking.
A good majority of the patients that walk through our doors are going to get some form of needle-stick, and no matter what, they aren’t going to like it. This can be one of the biggest challenges for us being that kids typically don’t tolerate pain as well as adults. Throw bad parenting into the mix and the problem only multiplies.
For the longest time, my solution to “sticking” pediatric patients was some form of restraint. Sometimes “burrito rolling” the kids in a blanket worked, other times the swat-team probably wouldn’t have been sufficient to keep them still long enough to start an IV. This all changed when I started my training in the ER.
There are 3 steps that we take to perform needle-sticks without our kids putting up a fight:
- Pain Management.
Before we do anything, we talk to the kids and tell them exactly what we are going to be doing in terms that can understand. The big key here is talking to them and the parents using the same words. If you talk to the kids using “kid-friendly” words, and then turn to the parents and re-explain what you just said using medical terms, the kids will view that as “code-talk” and you will lose their trust.
The other big trick is avoid words like “needle” or “poke”. Using less-threatening words will keep the anxiety level down and will help you get through the procedure without having to fight with them.
Here are some ideas for words that you can use to explain what you are about to do without scaring your patient:
- Straw = IV (Show them the catheter – minus the needle – and explain that it goes in their vein so you can give medicine to make them feel better.)
- Rubber band = Tourniquet (Tell you need to put a rubber band on their arm to see how big their muscles are.)
- Soap = Alcohol Swab (Explain that you need to use some soap to clean their skin “real good”)
Unless you have a form of pain management for invasive procedures like cold-spray or buffered-Lidocaine, you will have to explain that it’s going to hurt. The element of surprise isn’t going to do you any good in this situation. They will pull their arm away and immediately start to fight if you surprise them with a needle-stick. Try asking them if they have ever had anyone pinch them before, and explain that what you are going to do might “pinch for a little bit”. This may sound crazy, but I have personally found that making them promise that they will “let you know if it hurts”, has worked wonders.
A big part of this is also making sure you don’t attempt a needle-stick unless you are certain that you have an acceptable vein. You want to be done with the procedure as fast as you possibly can.
This is one of those things that works great, but nobody really thinks to do. Kids have the ability to build up high amounts of anxiety and stress, but they are also easily distracted. Carrying a few tools in your bag to grab their attention can pay off when it comes time to gain IV access on a sick kid.
This can be something like a game on your phone, a book, a toy, or some kind of activity for them to do while you do the dirty work. Obviously, having a second set of hands present will help with this step, but it’s not impossible to do by yourself.
One of my favorites is the i-spy books. They are big, which makes blocking the view of what you are doing easy. They require all of their attention as they have to find small objects on a big piece of paper, and best of all, they are cheap. If you have a second person available, have them hold the book up and search for the objects with them. If not, try propping it up or have them hold it with their “good arm”. You can always tell them to look for a specific object before you start the procedure.
If you are a high-tech, geeky, kinda medic like I am, then you can always get out your tablet, smart-phone, etc and let them play a game or watch a video. Of course, do this at your own risk. All of my devices have protective cases to help prevent damage from dropping.
This is one of those things that you may or may not have available at your service or hospital. I was recently introduced to the wonder of buffered-Lidocaine, and I’m not sure how I ever got by without it before.
I kid you not, using buffered-lidocaine through a J-Tip injector will eliminate any pain that would they would normally experience with a needle-stick. The J-Tip is a neat little device that forces the medication inside the syringe (in our case, Lidocaine) into the subcutaneous tissue around the vein by using a c02 cartridge. I have had it done to me, and I can honestly say that I didn’t feel a thing. The Lidocaine numbs the area good enough that the patients don’t even feel the needle-stick. I usually tell the kids that I’m going to give them “magic medicine” so they wont hurt.
The video below demonstrates the J-Tip injector. It’s pretty dry and boring, but if you fast-forward towards the end, you can actually see it being used on someone’s hand.
Chances are, you probably don’t have this available, but there are other options out there like cold-spray or topical anesthetics. If you don’t have access to any of these options, just remember to follow the first 2 steps. You will find that your pediatric patients will be much more cooperative and will be much easier to manage during your course of treatment.
If you have any methods to needle-sticks in pediatrics, please feel free to share below.